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Symptomatic Parotitis SYMPTOMATIC PAROTITIS BY B. N. TEBBS, M.A., M.D., B.C.CANTAB. Received June 6th-Read October 25th, 1904. SY3MPTOMATIC, seconldary, or mnetastatic parotitis is a subject round which mnuch interest and discussion have centred. A complication of other diseases, rather than a disease szti generis, it is best known, perhaps, as a sequela of abdominal operations and disorders, and of certain of the specific fevers, but there are many other conditions of which it is a recognised, if less common, complicationl. The only systematic study of the subject in this country is contained in the admirable papers by Mr. Stephen Paget (1) published in the years 1886 and 1887, which conistitute the chief source of our knowledge of this dis- order. Series of cases have also been published in America by Goodell and Morley (2), and in France by Benoit. The present paper is founded on a collection of 77 hitherto unpublished cases of this disorder, nearly all of which are taken from the records of St. George's Hospital. I must express my indebtedness to the members of the staff of that hospital for their kind permission to use these cases, anid to the other gentlemen who have kindly communicated cases to me. I have referred to other published cases but have not included them in the series. Anl analysis of the 77 cases will be found at the end of this paper. Previous observers have, I think, been rather inclined to VOL. LXXXVIII. 4 36 SYMPTOMATIC PAROTITIS look on the disorder as mnore or less of a specific disease, and to endeavour to adopt one explanation that will cover all the cases. Believing symptomatic parotitis to be a disease of rather heterogeneous pathogeny, I have attempted to classify the cases provisionally as follows: A. Acute parotitis following or in connection with (1) abdominal operations and diseases of the alimrentary cainal and its appendages; (2) operation on and disturbances of the generative organs; (3) operation on or injury of portions of the body other than the abdominal and pelvic viscera; (4) certain diseases of metabolism and chronic intoxications; (5) the specific fevers; (6) inflammatory conditions of neighbouring parts. B. Recurrent parotitis and chronic enlargement of the gland. The acute cases seem to fall naturally into two main groups, one of which is undoubtedly of septic and the other probably of toxic origin. Group 4, and probably some cases in group 3, represenit the toxic parotitis, and the other groups the septic variety. Some of the recurrent cases appear to depend largely, if not wholly, on vaso-motor disturba,nces, and would constitute a separate group. Believing that in the majority of the septic cases the infection of the gland arises not by a spread along the duct from the mouth but by the blood stream, I have paid special attention in the cases to the evidence of a primary septic focus, and to the co-existence of other septic com- plications in the patients that develop parotitis. I propose to treat these groups one by one, and finally to take up the consideration of certain general points in connection with the disorder. In the case of post-operative parotitis I have endeavoured to arrive at some idea of its relative frequency after various operations, by taking the total number of such operations performed durinig a period of fourteen years, and working out the percentage of cases followed by this complication. Cases fatal within forty-eight hours of operation may be excluded in reckoning percentages. SYMPTOMATIC PAROT[TIS 37 ACUTE PAROTITIS. 1. PAROTI'TIIS FOLLOWING OPERATION ON AND DISEASES OF THE ABDOMINAL VISCERA. Ga8tric O)peration8 and Disea8es. Of the various primary disorders that nay be followed by this complication lesions of the stomach would appear to furnish the greatest proportion of cases. I find that the complication reaches its highest percentage in connlec- tion with operations for gastric ulcer. During the fourteen years 1890 to 1903, 49 operations were performed in St. George's Hospital for gastric ulcer, 42 of which were for perforated ulcer and 7 for non-perforated, 5 of the latter involving opening of the stomach. Among the :38 patients who survived the operation for forty-eight hours there were 7 cases of parotitis, which gives a percentage of rather over 18 among surviving cases. The cases of perforated gastric ulcer formed the subject of a paper read before this Society last year by Mr. T. c. English (3). Parotitis formed only one of the numerous septic complications that arose in the surviving cases. Among 42 patients with perforated ulcer, of whom 32 survived operation for forty-eight hours, 15 developed pleurisy, 2 empyema, 3 pneumonia, 1 pulmonary abscess, 3 thrombosis, and 1 acute nephritis. Nearly all the patients that developed parotitis had some other septic complication. In case No. 1 of my series suppurative parotitis was followed by pulmonary abscess, empyema, and pericarditis. Cases Nos. 2 and 4 developed pleuLrisy, and No. 3 pneumonia, in addition to parotitis. These complications are to be ascribed to the septic soilinog of the peritoneum that occurs with the perforation of the ulcer. In cases of operation for non-perforated ulcer, other septic complications were, as might have been 38 SYMPTOMATIC PAROTITIS anticipated, less frequent. A numiiber of instances of parotitis after operation for gastric ulcer will be found in the literature. Dr. Phillips and Mr. Silcock (4) and Dr. Aitkeni (5) have recorded cases. In the former case the patient also developed a sub-diaphragmatic abscess and in the latter septic pneumonia. Dr. Blumer (6) records a case following excision of a gastric iulcer ; and Mir. Mansell Moullin, (7) in his report on thirteen cases of operation for recent gastric ulcer, mentions parotitis as occurring in two of the patients. One case in Morley's series followed operation for gastric ulcer. The relative frequency of parotitis after other gastric operations performed at St. George's Hospital is showin by the following table, which summarises the operations per- formed during a period of fourteen years: No. of No. of No. of cases surviving cases of Operation. cases. 48 hours. parotitis Gastro-enterostomny. 53 43 3 Gastrostoiny 35 31 1 Division of adhesions .7 7 1 Gastrotoiny 5 5 0 Gastroplication 2 2 0 Pyloroplasty .o 5 0 Loreta's operation 2 2 0 109 95 That is to say, parotitis occurred in rather over 5 per cent. of the patients that survived operation forty-eight hours. If we add to these the gastric ulcer cases, making in all 158 cases of operationi on the stomach, with 13:3 patients surviving forty-eight hours, and 12 cases of parotitis, we find a percentage of 9 for all gastric opera- tions. It will be noticed that the incidence of parotitis is considerably less in the cases contained in the above table (5 per cent.) than in cases of perforated gastric ulcer (18 per cent.), which is suggestive in view of the lesser degree of septic soiling of the peritoneum in the formier. Other septic complications are also less common than in cases of perforation. Case No. 12 in my series developed SYMPTOMlIATIC PAROTITIS 39 thiomlbosis in additioni to parotitis after the operatioln of gastro-enterostomny. Cases of parotitis following operations on the stomach xvill be founid in AIr. Paget's and in Alorley's series, and a case followiing gastrotomy for the remolval of a hair-ball is recorded by the late MIr. Knowsley Thornton (8). These figures would show that parotitis occurs as a well-marked complication of gastric operations, and that its frequency increases in proportion to the amount of peritoneal sepsis. [L Cases of Gast-ic Ulcer not treated by Operation. Although much less frequent than in the operative cases, parotitis forms a vell-marked com-plication of cases of gastric ulcer treated by medical measures. It occurs with such regularity that it seems remarkable that it has beeli so little recognised as a complication of this disease. Taking 652 consecutive cases, extending over a period of thirteen years, I found that it occurred thirteen times, or in exactly 2 per cent. of the patients. There was never any suspicion of an epidemic among the patients. The fact that the average period of starvation or rectal alimeenta- tioni in these cases was so much longer than in the operative cases is certainly suggestive of the inadequacy of the usually accepted explanation that parotitis is due to the cessation of mouth feeding, especially when wve consider the relative frequency of the complicat'ion in the cases treated surgically and those treated medically. Miloreover, the infectioln was of a much milder type in these mnedical cases, for in two only out of fifteen was there any suppuration, and in one of these it involved only the lyvnphatic glanlds over the mastoid process, and not the main parotid. In one case (No. 44) thrombosis occurred in addition to parotitis. A peculiar case is recorded by Dr. Sydney Phillips (9). A girl, aged 19, came under observation with symptoms strongly suggestive of perforated gastric ulcer, but appar- 40 4SYMPTOMATIC PAROTITIS ently due to thrombosis of the inferior veena cava, whiclh proved fatal. The patient developed parotitis, and a few days later the thrombosis, spreading dowinwards, appeared in the veins of the leg. Extensive thrombosis, extending right through the iliacs and inferior cava, was found at the autopsy. The patient was on rectal feeding for one day only. A possible explanation would seem to be that the parotid was predisposed to infection-the patient had had dyspeptic symptoms for some time-and that the organisms which were responsible for the thrombosis, reaching the gland by the blood streanm, set up the inflammatory process.
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